E-cigarette use in Kuwait: prevalence, knowledge, attitudes and beliefs

Abstract

The use of electronic cigarettes (e-cigarettes) as a smoking cessation aid or as a permanent replacement for smoking is increasing. The gateway theory states that e-cigarette use might lead to the use of combustible cigarettes by non-smokers, especially by adolescents. The aim of this PhD study was to investigate e-cigarette use by university student populations globally with a focus on UK and Kuwait student populations and their knowledge, attitudes and beliefs about e-cigarettes. In addition, the PhD study examined health policy development and production in Kuwait in order to consider and recommend ways in which to inform e-cigarette policy development in Kuwait. Initially, a systematic literature review and meta-analysis were conducted to evaluate the global prevalence of e-cigarette use in university-level students. Additionally, an online survey was carried out to evaluate the use of e-cigarettes and the knowledge, beliefs and attitudes of undergraduate and postgraduate students in Kuwait and Northern Ireland. A complementary analysis of health policy-related documents specific to Kuwait and a narrative literature review were conducted guided by the health policy triangle framework in order to improve understanding about policy development regarding the health of the population in Kuwait. Embase, Medline and Web of Science searches and subsequent screening and appraisal processes resulted in a total of 16 studies being included in the systematic review (SR) and meta-analysis. Overall, results showed that 17% (95% CI: 10% - 26%) of students reported ‘ever use’, 8% (95% CI: 4% - 11%) ‘dual-use’ and 73% (95% CI: 64% - 82%) ‘never use’ across university student populations up to the year 2018. Survey results from 1,105 United Kingdom (UK) and 152 Kuwaiti healthcare students revealed that e-cigarette ever use was higher in UK students (42%) compared to Kuwaiti students (18%). User age and main reasons for e-cigarette use, as well as perceptions of e-cigarette harm, were similar amongst the two student populations. The policy document review indicated that independent health policy processes within the Kuwait Ministry of Health were underdeveloped and that there was a reliance on ‘actors’ and influences that were external to Kuwait. The specific topic of tobacco or e-cigarette control was very low in the health policy agenda and, generally, policies were not informed explicitly by research evidence. In conclusion, this PhD research addresses the lack of research about the prevalence, knowledge and attitudes of the university student population in Kuwait regarding e-cigarette use. User age, key reasons for e-cigarette use and perceptions of e-cigarette harm appear to be similar amongst the two student populations. However, e-cigarette use particularly amongst healthcare students is lower in Kuwait compared to UK students. There is a general lack of detailed data relating to health policy processes and actors in Kuwait including in relation to tobacco control and e-cigarettes. Further research is required to improve understanding about how public health policy is made in Kuwait and, in particular, to study ways in which to incorporate the use of best available research evidence in health policy processes and strategic service planning for the improvement of population health.